I
would like to talk about the OPPSs for home health care and
ambulatory surgical settings. They are very different in how
they bill and are reimbursed
All nursing and other services provided by a home health
care agency are covered by Medicare Part A, and durable
medical equipment is covered by Part B. They are billed using
either the electronic 837 or the paper CMS-1450. The Request
for Anticipatory Payment (RAP) can be submitted as soon as
possible after the start of care. HHC agencies are paid by
episode of care, which is a 60-day period of time for each
physician certification. They are paid in a split percentage,
with the initial being in response to the RAP, and the final
being in response to the submitted claim. The amount is not
paid entirely in advance, but the amount is known. In the
event that a case uses more extensive resources, Medicare
can provide an Outlier payment to compensate. In HH PPS, the
resource groups are called home Health Resource Group
(HHRG) instead of DRG.
In Ambulatory Surgical Centers, each HCPCS code is assigned
to one ambulatory payment classification (APC), and there can
be an unlimited number of APCs per encounter for a patient.
The number of APC assignments is based on the number of
reimbursable procedures provided to that patient. Many
surgical procedures done on a patient on the same day are
due to a discount on the additional procedures. All services in
an APC are the same in both the clinical aspect and resource
use at the facility. The law says that the average cost for the
highest cost service in an APC can’t be more than two times
the average cost of the lowest cost service in the APC,
